- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,230.27
| Professional | | $851.14 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,089.30
| Professional | | $977.24 | $1,348.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,659.59
| Professional | | $1,047.13 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $1,548.82
| Professional | | $1,230.27 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $1,445.44
| Professional | | $891.25 | $1,174.90 | $1,445.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $1,318.26
| Professional | | $741.31 | $1,202.26 | $1,318.26 |